> <
 

Parathyroid Surgery Information

 
 

Parathyroid Disease

Parathyroid disease is due to abnormal function of one of four parathyroid glands in your neck. These are located on each side of your thyroid gland, although sometimes they can be in abnormal locations when they enlarge.

Most patients (95%) with parathyroid disease have one of four glands enlarged  (a parathyroid adenoma). The other 5%  have all four glands enlarged (parathyroid hyperplasia). Rarely there may be a so-called double adenoma. For those patients with one gland enlarged, surgery has evolved into Minimally Invasive Parathyroid Surgery. Patients with hyperplasia will usually require the traditional operation exploring both sides of the neck. They may require the removal of more then one gland.



Traditional and Minimally Invasive Parathyroid Surgery and
Intraoperative PTH


Traditional parathyroid surgery explores both sides of the neck to identify normal or abnormal parathyroid glands. The average patient has 4 glands, less the 1% may have 5 or more. Minimally invasive parathyroid surgery relies on pre-operative tests to localize the abnormal gland to one side. This permits a focused operation, significantly lowers the complication rate, operative time and post-operative course.

Minimally Invasive Parathyroid Surgery relies on either a  pre-operative study using radioactive isotopes (Sestamibi) or ultrasound. Sometimes both studies are done, and at times ultrasound is combined with CT scanning for further accuracy. Some medical centers report accuracy rates of almost 95% in localizing the side of an abnormal parathyroid gland before surgery. If the gland is found with a radioisotope before surgery, a device can be used during the surgery to help find the abnormal gland. (Gamma-probe, Navigator, etc.) This is called


Minimally Invasive Radio-guided Parathyroid Surgery or MIRPS.







Parathyroid Adenoma





Minimally Invasive Radio-guided Parathyroid Surgery (MIRP)

MIRP is not new. It has been performed throughout the United States for over 15 years. The technique utilizes the fact that most single enlarged parathyroid glands emit radioactivity when certain radioactive isotopes are injected into the human body. These isotopes concentrate in the parathyroid gland. The one almost all parathyroid surgeons use is called Sestamibi. It is rapidly taken up and rapidly excreted. The radioactive emission is very low and has no effect on other parts of the body in the diagnostic doses that are used. This technique is reserved for patients who have had a positive Sestamibi study preoperatively.


Patients are usually injected 1 to 1 1/2 hours prior to surgery They are then brought to the operating room.  The operation can be performed under either general or local anesthesia. This depends on the surgeons preference and the location of the abnormal gland. After anesthesia is obtained a small horizontal incision is made in a natural skin crease in the lower neck.  The deeper tissue on the side of the abnormal gland is explored and the area where the gland may reside is exposed. A radioactivity reading device, a gamma probe (see picture) is now used to map the surgical site, with higher emissions suggesting the location of the abnormal gland.


Once the gland is removed, it is measured for radioactivity off of the field. If it is higher then 20% of the baseline reading, it most likely is the enlarged parathyroid gland.  The surgeon may or may not look for another abnormal gland on the same side. If a second abnormal gland is found then the opposite side may be explored as well. These patients may be those who have Parathyroid Hyperplasia. More often the single gland (Parathyroid Adenoma) is the only abnormal one found.  After removal of the abnormal parathyroid gland(s) the wound is  closed with sutures and a dressing applied. Some surgeons may drain the wound. Most patients are discharged the same day. The scar is similar to that of thyroidectomy on the thyroid surgery page, only smaller.


Measuring Intraoperative Parathyroid Hormone (IOPTH)

PTH stands for parathyroid hormone. It is produced by the parathyroid gland and is the hormone or chemical in your blood that controls calcium levels in your body. It increases with parathyroid disease. PTH can be measured in the operating room to make sure it is returning to normal levels because of the parathyroid surgery being performed. It is known in the medical literature as Intraoperative PTH or IOPTH.
The surgical team compares the pre-operative parathyroid hormone level to one checked 5 to 10 minutes after the abnormal parathyroid gland is removed. The hormone level should drop by at least 50%. Sometimes if it does not drop further exploration to look for other abnormal glands is performed.


The Parathyroid Hormone molecule



Where is the surgery performed?

The operation is performed in the Hospital operating room. Most patients are admitted the day of surgery and go home either that evening or the following morning.


What type of anesthesia is used?

The operation is usually performed under general anesthesia (you are asleep). Some surgeons do the operation with the patient awake and with light sedation and local anesthesia. The safety of either approach is equal, however many surgeons prefer to perform the procedure under general anesthesia as it gives the surgeon more options during the operation. Some of these may be related to access to other parts of the neck or upper chest. This may be hard to do under awake/sedation anesthesia. General anesthesia gives the surgeon more control, and that enables the surgeon to achieve the goals of the procedure in a more expedient way.


Where is the neck cut?

The standard incision is in the lower neck about 2 to 3 inches above the collar bone. It is in the middle of the neck, a symmetrical “cut”– equidistant from both sides.  If the patient has a prominent crease in their neck, most surgeons will try to put the incision (cut) there.

The length of the incision depends on the size of the thyroid that needs to be removed. Usually it is no more then the size between the two large muscles that run up and down the neck. Sometimes it may be a bit larger if the patient has a goiter (a very enlarged thyroid gland). Trying to remove a large thyroid through a very small incision can lead to bruising, which may lead to poor healing and scaring. If there is a prior scar from previous thyroid surgery that site will usually be used for the incision.


Are there stitches and when do they come out?


Most stitches dissolve on their own in your body. There is one long stitch called a “pull-out” type which comes out five days to a week after surgery in the office. Surgical tape is placed on the wound and is changed during the first office visit after surgery.


Are drains used?

A small plastic drain may be placed at the time
of surgery and is removed before discharge from
the hospital.


            Post-operative  parathyroidectomy  scars


The Risks of Parathyroid Surgery

The main risks of parathyroid surgery are:                                       

Anesthetic risk

Bleeding after surgery

Injury to the nerves that work your vocal cords

Low blood calcium level

Failure to cure the disease


What to expect after surgery

You will usually wake up in the recovery room  You will have some pain in your throat and of your neck. You may have to go to the bathroom. There will be nurses in the recovery room to take care of your every need. They will administer medications and pain medicines and perform any other functions that are required for your post-operative care. You will be able to talk and will be able to start oral intake when you are fully awake. You will be followed closely by the surgical team. Blood will be drawn to follow your blood calcium level. If it is low it will be replaced. There will be a large bandage around your neck which will be removed before your discharge. If you have a drain in place it will be removed before you are discharged. You will have a waterproof bandage on your neck for 5 days, it will permit you to shower. Once you are discharged from the recovery room to a step-down or out-take unit you will be able to get out of bed, eat and converse with members of your family. Most parathyroid surgery patients go home after a 6 hour post-operative stay. You will usually see your surgeon 4 to 7 days after your surgery for suture removal and wound inspection. Your medications may be adjusted at that time.


Helpful links for more information

National Institute of Health


 

                          




This web site has been constructed for your benefit by

Arnold Komisar, MD, FACS.

1421 Third Avenue

New York, New York 10028

212-861-8888

212-472-3086 (Fax)

axk2@aol.com




@ 2007 A Komisar, MD, All rights reserved






 

Parathyroid Scan showing enlarged gland (Bright spot)